year old male with fever altered mental status54岁的男性发烧精神状态改变课件

54 year old male with HIV, 54 year old male with HIV, fever, altered mental statusfever, altered mental status Brian Crabtree, MD PGY-3Brian Crabtree, MD PGY-3 Maine ACP Conference 2013Maine ACP Conference 2013 September 28, 2013September 28, 2013 Identification and Chief ComplaintIdentification and Chief Complaint 54 year old Cuban American man with a 54 year old Cuban American man with a history of HIV positivity, schizoaffective history of HIV positivity, schizoaffective disorder, glaucoma, recent diagnosis of disorder, glaucoma, recent diagnosis of ankylosing spondylitis presents with three ankylosing spondylitis presents with three days of days of fevers and chillsfevers and chills, worsening , worsening headacheheadache and and confusion.confusion. History of Present IllnessHistory of Present Illness Mr. B was in his usual state of health until Mr. B was in his usual state of health until four days before admission when he reports four days before admission when he reports developing low grade fevers and night developing low grade fevers and night sweats with generalized malaise. Over the sweats with generalized malaise. Over the next two days he developed a worsening next two days he developed a worsening headache, confusion and ataxia. His headache, confusion and ataxia. His significant other brought him to the ED by significant other brought him to the ED by car for failure to improve and worsening car for failure to improve and worsening mental status.mental status. Review of SystemsReview of Systems General: +malaise, +fever, no weight lossGeneral: +malaise, +fever, no weight loss HEENT: +headache, no photophobia, +ulcer on lip for the HEENT: +headache, no photophobia, +ulcer on lip for the last week, no visual changeslast week, no visual changes CV: no chest pain, no DOE, no orthopneaCV: no chest pain, no DOE, no orthopnea Respi: no cough, no SOBRespi: no cough, no SOB GI: +nausea, no vomiting, no bowel changes, no abdominal GI: +nausea, no vomiting, no bowel changes, no abdominal painpain GU: +polydipsia and polyuria, no dysuriaGU: +polydipsia and polyuria, no dysuria Neuro: no focal weakness, no sensory deficits or paresthesiasNeuro: no focal weakness, no sensory deficits or paresthesias Skin: no rashes, no jaundiceSkin: no rashes, no jaundice Psych: +somnolence, +confusion, no hallucinations, delusionsPsych: +somnolence, +confusion, no hallucinations, delusions MSK: +neck stiffness, +low back pain, no joint painMSK: +neck stiffness, +low back pain, no joint pain Past Medical HistoryPast Medical History ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS HIV diagnosed in 1990s, currently on HIV diagnosed in 1990s, currently on antiretroviral therapy, most recent CD4 count antiretroviral therapy, most recent CD4 count 369 with low viral load (30)369 with low viral load (30) Schizoaffective disorder diagnosed in his mid Schizoaffective disorder diagnosed in his mid twenties and on valproic acidtwenties and on valproic acid Anklyosing spondylitis HLA-B27 positive, Anklyosing spondylitis HLA-B27 positive, diagnosed in the last yeardiagnosed in the last year History of uveitis and glaucomaHistory of uveitis and glaucoma Gilberts diseaseGilberts disease Chronic Hepatitis B carrierChronic Hepatitis B carrier HyperlipidemiaHyperlipidemia Past Medical HistoryPast Medical History ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B HIV diagnosed in 1990s, currently on HIV diagnosed in 1990s, currently on antiretroviral therapy, most recent CD4 count antiretroviral therapy, most recent CD4 count 369 with low viral load (30)369 with low viral load (30) Schizoaffective disorder diagnosed in his mid Schizoaffective disorder diagnosed in his mid twenties and on valproic acidtwenties and on valproic acid Anklyosing spondylitis HLA-B27 positive, Anklyosing spondylitis HLA-B27 positive, diagnosed in the last yeardiagnosed in the last year History of uveitis and glaucomaHistory of uveitis and glaucoma Gilberts diseaseGilberts disease Chronic Hepatitis B carrierChronic Hepatitis B carrier HyperlipidemiaHyperlipidemia Past Surgical HistoryPast Surgical History ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B TonsillectomyTonsillectomy Rectal fistula repairRectal fistula repair Social HistorySocial History ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Mr. B was Mr. B was born in Cubaborn in Cuba and moved to the United and moved to the United States at age 9. He is States at age 9. He is homosexualhomosexual with a with a long term partner. He was sexually active in long term partner. He was sexually active in New York City in the 1980s and was New York City in the 1980s and was diagnosed with diagnosed with HIV in the early 1990sHIV in the early 1990s. He . He has a has a history of drug usehistory of drug use including cocaine including cocaine and acid. Minimal current alcohol use, history and acid. Minimal current alcohol use, history of social tobacco use. He moved to southern of social tobacco use. He moved to southern Maine in 2009 to Maine in 2009 to run a kennelrun a kennel with his with his partner. He is partner. He is on disabilityon disability for his for his schizoaffective disorder.schizoaffective disorder. Medications and AllergiesMedications and Allergies ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Ritonavir 100mg cap dailyRitonavir 100mg cap daily Atazanavir 300mg cap dailyAtazanavir 300mg cap daily Emtricitabine-tenofovir 200-300mg tab dailyEmtricitabine-tenofovir 200-300mg tab daily Valproic acid 500mg 3 tabs at bedtimeValproic acid 500mg 3 tabs at bedtime Perphenazine 16mg tab twice dailyPerphenazine 16mg tab twice daily Bupropion 450mg XR once dailyBupropion 450mg XR once daily Pravastatin 20mg tab dailyPravastatin 20mg tab daily Etodolac 400mg tab twice dailyEtodolac 400mg tab twice daily Loratadine 10mg tab daily as neededLoratadine 10mg tab daily as needed Dorzolamide-timolol solution one drop twice dailyDorzolamide-timolol solution one drop twice daily Loteprednol etabonate 0.5% solution once dailyLoteprednol etabonate 0.5% solution once daily Physical ExaminationPhysical Examination ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B T 39.7 HR 107 RR 20 142/88 97% OT 39.7 HR 107 RR 20 142/88 97% O 2 2 General: drowsy, poor attention, orientedx3General: drowsy, poor attention, orientedx3 HEENT: PERRL, EOMI, +1cm ulcer on left lower lip, HEENT: PERRL, EOMI, +1cm ulcer on left lower lip, +nuchal rigidity+nuchal rigidity CV: regular rhythm, normal rate, normal S1 and S2 CV: regular rhythm, normal rate, normal S1 and S2 without murmurswithout murmurs Respi: good air movement, clear to auscultationRespi: good air movement, clear to auscultation Abd: soft and nontender, normal bowel sounds, no Abd: soft and nontender, normal bowel sounds, no organomegalyorganomegaly Ext: no peripheral edema, good pulsesExt: no peripheral edema, good pulses Neuro: cranial nerves 2-12 tested and intact, 5/5 strength Neuro: cranial nerves 2-12 tested and intact, 5/5 strength throughout, normal reflexes, negative Kernig and throughout, normal reflexes, negative Kernig and Brudzinski signs, normal tone, normal sensationBrudzinski signs, normal tone, normal sensation Initial Lab TestingInitial Lab Testing ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B CBC: WBC 7.0, Hb 13.2, Hct 37.2, Plt 177CBC: WBC 7.0, Hb 13.2, Hct 37.2, Plt 177 BMP: BMP: Na 122Na 122, K 3.8, Cl 84, CO, K 3.8, Cl 84, CO 2 2 24 24 BUN 10, Cr 1.2, Glu 109 BUN 10, Cr 1.2, Glu 109 UA/sediment: pH 5.0, negative leukocytes and UA/sediment: pH 5.0, negative leukocytes and nitrites, +urobilinogen, no casts, 3-5 RBCs, nitrites, +urobilinogen, no casts, 3-5 RBCs, occasional WBCsoccasional WBCs Differential DiagnosisDifferential Diagnosis ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS 3. Hypo-3. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Infectious: Sepsis of any origin, Infectious: Sepsis of any origin, meningoencephalitis, brain abscessmeningoencephalitis, brain abscess Autoimmune: CNS vasculitis, Stills diseaseAutoimmune: CNS vasculitis, Stills disease Malignancy: Lymphoma, leukemiaMalignancy: Lymphoma, leukemia Environmental: Heat strokeEnvironmental: Heat stroke Toxins: Neuroleptic malignant syndrome, Toxins: Neuroleptic malignant syndrome, salicylate overdose, serotonin syndrome, salicylate overdose, serotonin syndrome, anticholinergic toxicity, sympathomimetic anticholinergic toxicity, sympathomimetic toxicitytoxicity Metabolic: ThyrotoxicosisMetabolic: Thyrotoxicosis Chest X rayChest X ray CT HeadCT Head MR BrainMR Brain Clinical Course in the EDClinical Course in the ED ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS 3. Hypo-3. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Lumbar puncture was attempted six times and was finally Lumbar puncture was attempted six times and was finally successful. The patient remained febrile. successful. The patient remained febrile. Results of lumbar puncture showed:Results of lumbar puncture showed: WBC 206/mm WBC 206/mm 3 3 with 86% lymphocytes with 86% lymphocytes Glucose 52 mg/dL Glucose 52 mg/dL Protein 91 mg/dL Protein 91 mg/dL No RBCs No RBCs Gram stain negative Gram stain negative Blood cultures were taken and empiric acyclovir was Blood cultures were taken and empiric acyclovir was initiated.initiated. Interpreting CSFInterpreting CSF ActiveActive ProblemProblem ListList 1. Fever1. Fever 2. AMS2. AMS 3. Hypo-3. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Results of lumbar puncture showed:Results of lumbar puncture showed: WBC 206/mm WBC 206/mm 3 3 with 86% lymphocytes with 86% lymphocytes Glucose 52 mg/dL Glucose 52 mg/dL Protein 91 mg/dL Protein 91 mg/dL No RBCs No RBCs Gram stain negative Gram stain negative EtiologyEtiologyWBC WBC cells/mmcells/mm 3 3 Primary cell typePrimary cell typeGlucose Glucose mg/dLmg/dL Protein Protein mg/dLmg/dL BacterialBacterial1000-50001000-5000NeutrophilNeutrophil454550-20050-200 FungalFungal20-50020-500MononuclearMononuclear4545 TuberculousTuberculous50-30050-300MononuclearMononuclear38continued having fevers 38 C multiple times C multiple times per day for three days. Vancomycin and per day for three days. Vancomycin and ceftriaxone were added empirically, but he ceftriaxone were added empirically, but he continued to have fevers that would respond continued to have fevers that would respond to acetaminophen. His mental status to acetaminophen. His mental status continued to fluctuate and he continued to continued to fluctuate and he continued to have back pain and stiff neck.have back pain and stiff neck. Clinical CourseClinical Course Work-up for Aseptic MeningitisWork-up for Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Aseptic 1. Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Infectious workup:Infectious workup: Blood and CSF cultures negative at 48 hoursBlood and CSF cultures negative at 48 hours CSF Cryptococcal antigen: negativeCSF Cryptococcal antigen: negative T-spot: negativeT-spot: negative T pallidum Ab: negativeT pallidum Ab: negative Lyme IgG and IgM Ab: negativeLyme IgG and IgM Ab: negative CSF HSV PCR: negativeCSF HSV PCR: negative CSF arbovirus panel: negativeCSF arbovirus panel: negative CD4 count: 342CD4 count: 342 HIV viral load: 30 copies/mLHIV viral load: 30 copies/mL Rheumatologic workup:Rheumatologic workup: ESR: 22ESR: 22 CRP: 0.56CRP: 0.56 Work-up for Aseptic MeningitisWork-up for Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Aseptic 1. Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Drug Induced Aseptic Meningitis Drug Induced Aseptic Meningitis - Most common offending medications include - Most common offending medications include ibuprofen, other NSAIDs, lamotrigine.ibuprofen, other NSAIDs, lamotrigine. - Difficult to test for and is often a diagnosis - Difficult to test for and is often a diagnosis of exclusion. Diagnosis depends on causal of exclusion. Diagnosis depends on causal relation with drug administration and is relation with drug administration and is confirmed with pharmacologic challenge confirmed with pharmacologic challenge testing where medication is given and clinical testing where medication is given and clinical response is monitored.response is monitored. = ibuprofen administration Drug-Induced Aseptic MeningitisDrug-Induced Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Drug-1. Drug- induced induced Aseptic Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B First described in 1978 in a 26 year old female First described in 1978 in a 26 year old female with lupus who developed meningitis while with lupus who developed meningitis while taking ibuprofen. The diagnosis was taking ibuprofen. The diagnosis was confirmed with challenge testing.confirmed with challenge testing. Body of evidence regarding drug-induced aseptic Body of evidence regarding drug-induced aseptic meningitis (DIAM) is largely based on case meningitis (DIAM) is largely based on case reportsreports A 2006 review article reviewed 71 cases of A 2006 review article reviewed 71 cases of NSAID-induced meningitis. 61% of cases had NSAID-induced meningitis. 61% of cases had an underlying connective tissue diseasean underlying connective tissue disease HIV has been mentioned as a predisposing HIV has been mentioned as a predisposing condition as wellcondition as well Exact incidence is unknownExact incidence is unknown History and EpidemiologyHistory and Epidemiology Drug-Induced Aseptic MeningitisDrug-Induced Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Drug-1. Drug- induced induced Aseptic Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Clinical FeaturesClinical Features Rodriguez, SC. Characteristics Rodriguez, SC. Characteristics of meningitis caused by of meningitis caused by ibuprofen: report of 2 ibuprofen: report of 2 cases and review of the cases and review of the literature. Medicine literature. Medicine (Baltimore) 2006 Jul; (Baltimore) 2006 Jul; 85(4) 214-20.85(4) 214-20. Drug-Induced Aseptic MeningitisDrug-Induced Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Drug-1. Drug- induced induced Aseptic Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B Thought to be a type III hypersensitivity Thought to be a type III hypersensitivity reaction against the drug or metabolitereaction against the drug or metabolite One suggested mechanism is hypersensitivity to One suggested mechanism is hypersensitivity to the drug as a hapten with an CSF-protein the drug as a hapten with an CSF-protein which would explain the limitation of the which would explain the limitation of the inflammation to only the central nervous inflammation to only the central nervous system.system. Some patients have idiosyncratic reactions to Some patients have idiosyncratic reactions to only one NSAID while others have been only one NSAID while others have been described as having reactions to several drugs described as having reactions to several drugs within the classwithin the class Proposed MechanismProposed Mechanism Drug-Induced Aseptic MeningitisDrug-Induced Aseptic Meningitis ActiveActive ProblemProblem ListList 1. Drug-1. Drug- induced induced Aseptic Aseptic MeningitisMeningitis 2. Hypo-2. Hypo- natremianatremia PMHPMH 1. HIV1. HIV 2. Schizo-2. Schizo- affective affective disorderdisorder 3. Akylosing 3. Akylosing spondylitisspondylitis 4. Chronic 4. Chronic Hepatitis BHepatitis B C